Appendectomy

Sony Wijaya

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Appendicitis ?
Why...???

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 ABDOMEN AKUT
DEFINISI
• Abdomen akut adalah keadaan yang memerlukan
keputusan segera” (FD Moore, 1977)
– Haruskah menjalani operasi?
– Bila harus, kapan sebaiknya dioperasi?
ISTILAH LAIN
• Gawat Abdomen (Buku Ajar Ilmu Bedah, 1997): “keadaan
klinik akibat kegawatan di rongga perut yang biasanya
timbul mendadak dengan nyeri sebagai keluhan utama”
• Nyeri abdomen akut: karena keluhan utama nyeri akut
(Nyhus, Vitello, Condon, 1995)

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 Mengapa Nyeri Abdomen Akut istimewa?

• Pasien dengan nyeri abdomen akut:

– keluhan baru saja terjadi
– penyebab belum diketahui
– harus segera didiagnosis dan terapi

– mencegah mortalitas atau morbiditas berat

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 Mengapa tindakan harus segera?
• Tiap menit berharga, keterlambatan terapi fatal
– Semua perdarahan masif trauma & non-trauma dengan respons
transien atau tanpa respons terhadap resusitasi
– Thrombosis arteri mesenterial  katastrof abdomen
– Strangulasi usus dengan ancaman nekrosis luas

• Tiap jam berharga, keterlambatan terapi  meningkatkan

morbiditas dan mortalitas
– Perforasi ulkus peptikum
– Perforasi tifus
– Thrombosis vena mesenterial

• Keterlambatan lebih dari 12 jam  meningkatkan morbiditas &

mortalitas
– Ileus obstruksi total
– Ileus strangulasi
– Closed loop syndrome
– Perforasi kolon
– Appendicitis gangrenosa
– Colitis fulminans Powerpoint Templates Page 5
Appendicitis ?
Why...???

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 APPENDICITIS

• Appendicitis is defined as an inflammation

of the inner lining of the vermiform appendix
that spreads to its other parts. This
condition is a common and urgent surgical
illness with protean manifestations,
generous overlap with other clinical
syndromes, and significant morbidity, which
increases with diagnostic delay.

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Incidence

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 Incidence
• The lifetime rate of appendectomy is 12% for men and 25% for
women, with approximately 7% of all people undergoing
appendectomy for acute appendicitis during their lifetime
• Despite the increased use of ultrasonography,
computed tomography (CT), and laparoscopy,
the rate of misdiagnosis of appendicitis has remained
constant (15.3%), as has the rate of appendiceal rupture.
• The percentage of misdiagnosed cases
of appendicitis is significantly higher
among women than among men.

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Incidence Function

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 There Is No one can ensure the
function of the Appendix.
Hipotesis
• “Important Biological function ; as a bacteria
reservoar”
 2012 : That Individuals without an appendix were four times
more likely to have recurrence of Clostridium Defficile Colitis
 L’ Casei Shirota Strain

• GALT : Gut Associated Lymph Tissue

 Mucosal Associated Lymph Tissue  plasmosit
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 Incidence Function

Complication

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 Complication
• Perforation
• Peritonitis
• Appendiceal Mass/Infiltrat
• Appendiceal Abscess
• Phylephlebitis

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High Risk Patients

Ovulating women
PID, TOA, ovarian cyst rupture can mimic
appendicitis
Look for cervical motion tenderness,
adnexal tenderness, history of STD’s
Can have diguised with pelvic appendix

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 High Risk Patients,

Pregnancy
Most common surgical emergency in
pregnancy
Mortality rate if missed = 2 % for mother,
up to 35 % for fetus
WBC elevated in pregnancy
Appendix changes location

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 High Risk Patients,
Pediatrics
Most common surgical disorder in kids
Accounts for 5 % of abd. pain visits
Up to 50 % initially misdiagnosed
ƒ < 2 yrs. : perforation rate approaches 100 %
ƒ 3 to 5 yrs. = 71 %

ƒ 6 to 10 yrs. = 40 %

Most common misdiagnosis is Acute

GAstroenteritis
Sequence of pain and vomiting may be helpful
Localized tenderness not a feature of Acute
Gastroenteritis Powerpoint Templates Page 16
High Risk Patients,

Elderly
Vital signs and exam may not reflect
severity
> age 60 : only 5 to 10 % diagnosed
without delay
Perforation rate = 46 to 83 %
RLQ tenderness absent in 23 %
N/V, anorexia less common
Leukocytosis less pronounced
Only 20 % classic presentation
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 Ai Onishi (109 y.o; diagnosed as
Acute Appendicitis at 22 Feb
2012 and has undergone
succesful Appendectomy 
Towakai Hospital Takasuki
Osaka, Japan

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High Risk Patients.
Immunocompromised
HIV, chronic steroids, sickle cell,
chemotherapy, DM, dialysis
Increased risk of complications and
misdiagnosis
Inflammatory response decreased

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 Incidence Function

Complication Costs

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 Indonesia ?

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 Anatomy
• The three taeniae coli converge at the
junction of the cecum with the appendix
and can be a useful landmark to identify
the appendix.
• The appendix can vary in length from <1
cm to >30 cm;
• most appendices are 6 to 9 cm long.

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 Variations in topographic position of the
appendix

From its base at the cecum, the appendix may extend (A) upward, retrocecal and
retrocolic; (B) downward, pelvic; (C) downward to the right, subcecal; or (D) upward to
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the left, ileocecal (may pass anterior Templates
or posterior to the ileum) Page 24
Surgical Anatomy - Position

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 Pathogenesis
Distention
causing
Ischemia

obstruction mucus
Distention

Gangrene

Appendiceal Appendiceal Irritation of parietal Perforation,

obstruction/early distension peritoneum localised/generalised
appendicitis – (localised) peritonitis, mass
visceral peritoneal
irritation

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 Symptoms
1-Abdominal pain is the prime symptom of acute
appendicitis.
Classically, pain is initially diffusely centered in the lower
epigastrium or umbilical area, is moderately severe, and is
steady, sometimes with intermittent cramping superimposed.

After a period varying from 1 to 12 hours, but usually within 4

to 6 hours, the pain localizes to the right lower quadrant

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 Sifat dan Intensitas Nyeri
A

• A. Nyeri Sakit Gigi  Kolik Intermiten

• C. Nyeri Kolik dan Awal Radang pada awal obstruksi organ
Organ Berrongga berongga

 Nyeri Kolik tanpa interval bebas nyeri

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Pada obstruksi Templates
usus lanjut oleh karena mulai ada iskemi Page 28
 Symptoms
2-Anorexia nearly always accompanies appendicitis. It is so constant that
the diagnosis should be questioned if the patient is
not anorectic.

3-vomiting occurs in nearly 75% of patients

4-obstipation beginning before the onset of abdominal pain

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 Keypoint
The sequence of symptom appearance has great
significance for the differential diagnosis. In >95% of
patients with acute appendicitis, anorexia is the first
symptom, followed by abdominal pain, which is followed,
in turn, by vomiting (if vomiting occurs). If vomiting
precedes the onset of pain, the diagnosis of appendicitis
should be questioned.

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Physical Examination

• Rovsing’s sign
• Obturator sign
• Psoas sign

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 Physical Examination

Digital Rectal Examination : Don’t Miss It !!!

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Laboratory Studies

CBC
75 to 85 % have elevated WBC, but it is
nonspecific
WBC normal in 80 % in the first 24 hrs.
Can see elevated Acute Netrophil Counts
in up to 89 %
WBC usually 12 to 18,000 in appendicitis
Chemistry panel
May help with diagnosis of dehydration
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Laboratory Studies, cont'd.

Urinalysis
Specific gravity, ketones
Can see WBC’s, RBC’s, bacteria if
inflamed appendix close to ureter
> 30 WBC’s = probable UTI
HCG
Essential in women of child-bearing age
CRP
Acute phase reactant
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 Imaging Studies

Plain films
Low sensitivity and
specificity
Appendicolith specific, but
seen in only 2 %
May see local air-fluid
levels, psoas obliteration,
soft tissue mass, gas in
appendix : all nonspecific
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Imaging Studies, cont'd.
Ultrasound
75 to 90 % sensitive, 86 to
100 % specific
Noninvasive, low cost, but
operator-dependent
Good for diagnosing GYN
disorders
3 criteria for diagnosis
ƒ Tender, noncompressible
appendix
ƒ No peristalsis of appendix

ƒ Overall diameter > 6 mm

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Imaging Studies, cont'd.

Ultrasound (US)
Appendix may not be seen, due to obesity,
guarding, bowel gas, perforation,
retrocecal location
2.4 to 56 % of normal appendixes seen
One study of 736 pediatric patients
showed 36.6 % without preop US had
negative appendectomy vs. 9.8 % who had
US
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Imaging Studies, cont'd.

Ultrasound
Study from Australia showed total WBC
and neutrophil count were more accurate
than US. They recommended pts. with
unequivocal presentation go to OR. If
equivocal, obtain CBC. If WBC > 15,000, go
to OR. If < 11,000, obtain CT (US only in
pregnancy).

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Imaging Studies, cont'd.

CT
Early studies showed low yield, but helical
CT much more accurate
Sensitivity 97 to 100 %, specificity 95 %
(similar no matter what type or whether
contrast is used)
Often shows alternative diagnosis
More expensive, radiation exposure

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Imaging Studies, cont'd.
CT
Criteria for appendicitis :
Diameter > 6 mm
ƒ

ƒ Failure to completely fill

with contrast or air
ƒ Appendicolith

ƒ Wall thickening or
enhancement
Other contributory signs
include fat stranding, fluid,
inflammatory mass,
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 Do We Need Imaging Studies?

NEJM : Suspected Appendicitis Jan. 2003

Patients with classic presentation should go to
O.R. Diagnostic accuracy approaches 95 %
If equivocal or suspect perforation : CT
US reserved for pregnant women or high
suspicion of GYN disease
If study indeterminate, observe with repeated
exams or laparoscopy

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MANTRELS Score

Established in 1986
Migration of pain
Anorexia
Nausea / vomiting
Tenderness RLQ
Rebound
Elevated temp.
Leukocytosis
Shift to left
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MANTRELS Score, cont'd.
RLQ tenderness and leukocytosis = 2
points each ; all others 1 point

Score of 5 to 6 = possible appendicitis

Score of 7 to 8 = probable appendicitis

Scoreof 9 to 10 = very probable

appendicitis
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Risk Management
Misdiagnosis of appendicitis = 5th
leading cause of successful litigation
against EPs
7 features of misdiagnosed cases :
No nausea / vomiting
Lack of distress
No rebound
No guarding
No rectal exam (controversial)
Narcotic pain meds given
Diagnosis of acute gastroenteritis
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Risk Management, cont'd.

When discharging, stress unclear

diagnosis, what to watch for
Follow up in 12 hours (PMD or E.D.)
Can always observe if unsure
"When in doubt, don't send them out."

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 Perjalanan penyakit apendisitis
1. Obstruksi lumen usus → sekresi dari mukus dan cairan
terus menerus → peningkatan dari tekanan luminal
2. ketika peningkatan dari tekanan luminal melebihi dari
tekanan venula dan limfatik submukosal → aliran darah
dan limfatik akan terhambat → peningkatan tekanan dari
dinding apendiks
3. bila tekanan luminal melebihi tekanan kapiler → iskemik,
inflamasi dan ulserasi dari mukosa apendiks
4. Pertumbuhan berlebihan dari bakteri pada lumen
apendiks → inflamasi, edema dan nekrosis

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 Pathophysiology of Appendicitis
Lymphoid hyperplasia leads to luminal
obstruction
Often follows viral illness
Epithelial cells secrete mucus
Appendix distends, bacteria multiply
Visceral pain begins an average of 17 hours after
obstruction
Increased pressure compromises blood supply
Somatic pain develops
Average time to perforation = 34 hrs.
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• Tanda-tanda:
Rovsing’s sign → nyeri di kuadran kanan bawah
ketika ditekan pada kuadran kiri bawah (pada
daerah kontralateral), menggambarkan adanya
iritasi dari peritoneum

Psoas sign → pasien yang diposisikan pada sisi

kiri dan dilakukan ekstensi pada sendi panggul
menghasilkan nyeri. Nyeri tersebut merupakan
akibat dari iritasi musculus psoas kanan dan
menandakan iritasi yang terletak retrocaecal dan
retroperitoneal dari phlegmon maupun abses

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Obturator sign → pasien dalam posisi
berbaring melakukan fleksi sendi panggul kanan
lalu dilakukan rotasi interna secara pasif. Nyeri
menandakan adanya inflamasi pada daerah di
dekat musculus obturator pada pelvis mayor.

Blumberg sign → nyeri di kuadran kanan bawah

ketika tekanan pada kuadran kiri bawah dilepaskan.

Dunphy’s sign → adanya rasa nyeri yang tajam pada

kuadran kanan bawah bila sengaja dibatukkan
(cough sign)
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 APPENDICITIS GANGRENOSA
• nekrosis dari dinding appendiks akibat
pertumbuhan bakteri yang berlebihan dan iskemi
dari appendiks.
• mempunyai durasi gejala yang lama, panas tinggi,
dan leukosit yang lebih tinggi (>18.000 / mm3).
• komplikasi
Phylephlebitis adalah trombophlebitis suppuratif
dari sistem vena portal. Gejala klinisnya berupa
rasa menggigil, panas tinggi, ikhterus, dan
selanjutnya dapat menjadi abses hepatika

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APPENDICITIS PERFORASI
• Keterlambatan dalam mencari perawatan medis, adanya fekalit
dalam lumen, dan umur (orang tua atau anak muda) merupakan
faktor yang dapat menyebabkan terjadinya ruptur / perforasi. Ruptur
appendiks terutama terjadi pada distal dari obstruksi lumen
• Faktor yang mempengaruhi tingginya insidens perforasi pada orang
tua → adanya gejala yang samar, keterlambatan berobat, adanya
perubahan anatomi appendiks berupa penyempitan lumen, dan
arteriosklerosis.
• insidens tertinggi pada anak → dinding appendiks yang masih tipis,
anak kurang komunikatif sehingga memperpanjang waktu diagnosis
dan proses pendindingan yang kurang sempurna akibat perforasi
berlangsung cepat dan omentum anak belum berkembang.

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• Gejala dan tanda
demam yang > 39oC, rasa nyeri yang lebih parah, dan leukosit >
18.000 / mm.
• Komplikasi
Peritonitis lokal → perforasi mikroskopik dari appendiks gangrenosa
peritonitis umum → perforasi besar sehingga isi lumen masuk ke
dalam rongga peritoneum.
Gejala-gejala seperti peningkatan kekakuan otot abdomen, distensi
abdomen, dan peristaltik yang berkurang terlihat pada pasien yang
mengalami peritonitis.
• Terapi
Kebanyakan dari pasien-pasien ini mengalami penurunan volume
cairan sehingga membutuhkan waktu 2 jam atau lebih untuk
resusitasi cairan sebelum operasi. sudah mengalami peritonitis dan
membutuhkan antibiotik spektrum luas secara intravena yang harus
diberikan sesegera mungkin.

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 MASSA PERIAPPENDICEAL
• Massa appendiks ini terjadi bila appendicitis
gangrenosa atau mikroperforasi ditutupi oleh
pendindingan oleh omentum dan / atau lekuk usus
• Gejala dan tanda
terabanya massa pada kuadran kanan bawah
• Terapi
massa periappendikular yang masih mobile di
operasi segera untuk mencegah penyulit tersebut.
massa periappendikular yang terfiksir dan
pendindingan sempurna, dirawat dulu dan diberi
antibiotik
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